RHIA Exam Prep | 50 Questions with 100% Correct Answers | Verified | Latest Update 2024

The Medical Record Committee is deciding how interim reports should be handled. What is the best practice? - Maintain all interim reports for the greatest measure of security This report should be written or dictated immediately after the procedure is done and filed in the patient's health record as soon as possible. - Operative Report Highland Hospital requires all dates be recorded as MM/DD/YYYY. This required data definition and format should be part of the _____ _____. - Data Dictionary A _____ _____ is like a map of the database, ensuring consistency by standardizing definitions. - Data Dictionary The SOAP format is an example of a structured progress note commonly used with what type of health record? - Problem Oriented What does SOAP stand for? - S: subjective O: objective A: assessment P: plan What does ERD stand for? - Entity Relationship Diagram